pituitary disorders
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Pituitary disorders
Narendra ReddyClinical LecturerDiabetes, Endocrinology & MetabolismUniversity of Warwick
Grand round, UHCW, June 14th 2011
Plan….
Pituitary anatomy Pituitary physiology Evaluation of Pituitary mass Pituitary dysfunction in Elderly Clinical scenarios/Images
Pituitary anatomy
Pituitary anatomy
Sagittal view
Coronal view
Coronal view
Hormones
Evaluation of Pituitary mass
Local effects
Hypersecretion
Hyposecretion
Pituitary hormone profile
Somatotroph – GH IGF-1 Gonadotroph – FSH,LH Testo/Oest Thyrotroph – TSH FT4,FT3 Corticotroph – ACTH Cortisol (SST) Lactotroph - Prolactin Neurohypophysis Vasopressin (U&E, Paired Osmol)
Case
82 yr old male Headache, diplopia, vomiting- Acute Hypotension- 90/45 mmHg & III N palsy PMH- IHD, Hypertension Drugs- Antihypertensives, Aspirin
Diagnosis?
Investigations
9 am Testo- <0.4 (10-26) LH- 1.2, FSH- 0.7 (2-10) IGF-1 – 4.8 (10-35) PrL- 322 (<300) FT4 8.8 (10-19.5), TSH 2.0 (0.5-4.5) SST – 30’ Cortisol 213 nmol/L Na - 122; Pl Osm & U Osm - normal
Pituitary apoplexy
Pituitary apoplexy
Pituitary apoplexy
Pit apoplexy guidelines
Chronic hypopit’ symptoms
GH- lethargy, reduced strength LH/FSH- libido, infertility, menstrual TSH – hypothyroid PrL- lack of milk in breastfeeding females ACTH – pallor Vasopressin – Diabetes Insipidus
Hypopituitarism Pituitary tumours Radiotherapy Apoplexy,Sheehan syndrome Infiltrative disorders Infective- TB, Pit abscess Trauma Metastasis Russell viper snake bite PIT-1, HESX-1, PROP-1, KAL-1, SOX-2, DAX-1,
AVP-Neurohypophysin-II
Dynamic tests
Insulin Tolerance Test- ACTH & GH Glucagon test – ACTH & GH SST- adrenocortical function Clomifene test – Gonadotrophin GnRH & TRH- rarely used
To take home….
Adenomas do not cause DI
GH>FSH/LH>TSH>ACTH
Long term hypopit patients, treated with steroids can unmask DI
ACTH def–No Pigment/Hyperkalaemia
84 pts over 65 yrs (avg 72.5 yrs) 1975 to 1996 64 % VF defects 20 % hypopituitarism 7% pituitary apoplexy TSA safe in elderly
Pit tumours in elderly
Pituitary Incidentalomas
10% incidence in 18902 pituitaries Minimum 20 years F/U 18-86 years Local, hypersecretion, hyposecretion 10.6% < 1cm 24.1 % if >1cm MRI – 1, 2 & 5 years- stop if no size Hypopit, VF defects & size increase- Sx
Mark Molitch,Best Practice in Clinical Research 23 (2009) 667–675
42 yr man Headaches Reduced libido Erectile dysfunction
Case
2007
20 days
9 months
3 years
Prolactinoma Micro <1cm ; Macro > 1cm Medical treatment- Cabergoline Surgery- DA resistance/intolerance Radiotherapy DA Rx – Cardiac Valve fibrosis
1st line- Sx
2ndline- Mx
3rd line-Dx
Case
20 year old boy Visual field problems Enlarged nose Carpal tunnel Syndrome
Acromegaly
Photos please...
2nd line- Mx
1st line- Sx
3rd line- Dx
Case
40 years old lady 10 years of Diabetes Hypertension Hyperlipidaemia Osteoporosis Wt gain Acne
Cushings disease
Dr Harvey Cushing
Management ONDMST - Cortisol > 50 24 hr Urine Free Cortisol LDDMST >50 HDDMST CRH stimulation test Petrosal sinus sampling Surgery Radiotherapy B/L Adrenalectomy
1st line- Sx
2nd line-Dx
3rd line- Sx
Non functioning Pit Adenomas(NFA)
NFA
?????
Rathkes cyst
???
Craniopharyngioma
40 yr old female,Hypothyroid
?????
Lymphocytic hypophysitis
Lymphocytic hypophysitis
Young women Auto immune Prodromal illness VF defects Hormone deficiencies Bx- diagnostic
Meningioma
Hormones !!
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